Current through Register Vol. 49, No. 9, September, 2024
ATTACHMENT 3.1-A
Page 1d
AMOUNT, DURATION, AND SCOPE OF SERVICES
PROVIDED
Revised: October 1, 2023
CATEGORICALLY NEEDY
2a. Outpatient Hospital Services (Continued)
Non-Emergency Services
Outpatient hospital services other than those which qualify as
emergency, outpatient surgical procedures and treatment, and therapy services
are covered as non-emergency services.
Benefit Limit
Outpatient hospital services are limited to a total of twelve
(12) visits a year. This yearly limit is based on the State Fiscal Year - July
1 through June 30. Outpatient hospital services include the following:
* non-emergency outpatient hospital and related physician and
nurse practitioner services; and
* outpatient hospital therapy and treatment services and
related physician and nurse practitioner services.
For services beyond the 12-visit limit, an extension of
benefits will be provided if medically necessary. The following diagnoses are
considered categorically medically necessary and do not require prior
authorization for medical necessity: Malignant neoplasm; HIV infection; renal
failure; opioid use disorder when the visit is part of a
Medication Assisted Treatment Plan; and pregnancy. All other
diagnoses are subject to prior authorization before benefits can be
extended.
Outpatient hospital services are not benefit limited for
recipients in the Child Health Services (EPSDT) Program.
2b. Rural Health Clinic Services
5. Services of nurse midwives
6. Visiting nurse services on a part-time or
intermittent basis to home-bound patients (limited to areas in which there is a
shortage of home health agencies).
Rural health clinic ambulatory services are defined as any
other ambulatory service included in the Medicaid State Plan if the Rural
health clinic offers such a service (e.g. dental, visual, etc.). The "other
ambulatory services" that are provided by the Rural health clinic will count
against the limit established in the plan for that service.
Medication Assisted Treatment visits do not count against the
Rural Health Clinic encounter benefit limit when the visit is part of a
Medication Assisted Treatment plan.
2c.
Federally qualified health
center (FQHC) services and other ambulatory services that are covered under the
plan and furnished by a FQHC in accordance with Section 4231 of the State
Medicaid Manual (NCFA - Pub.
45-4). Federally qualified health center services
are limited to sixteen (16) encounters per client
, per State
Fiscal Year (July 1 through June 30) for clients twenty-one (21) years or
older. The applicable benefit limit will be considered in conjunction with the
benefit limit established for physicians' services, medical services furnished
by a dentist, office medical services furnished by an optometrist, certified
nurse midwife services, rural health clinic encounters, and advanced practice
registered nurse services, or a combination of the seven.
For federally qualified health center core services beyond the
benefit limit, extensions will be available if medically necessary.
Beneficiaries under age twenty-one (21) in the Child Health Services (EPSDT)
Program are not benefit limited.
FQHC hospital visits are limited to one (1) day of care for
inpatient hospital covered days regardless of the number of hospital visits
rendered. The hospital visits do not count against the FQHC encounter benefit
limit.
Medication Assisted Treatment visits do not count against the
FQHC encounter benefit limit when the visit is part of a Medication Assisted
Treatment plan.
3.
Other Laboratory and X-Ray Services
Other professional and technical laboratory and
radiological services are covered when ordered and provided under the
direction of a physician or other licensed practitioner of the healing arts
within the scope of his or her practice, as defined under
42 CFR
440.30 in an office or similar facility other
than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are
limited to five hundred dollars ($500) per State Fiscal Year (SFY,
July 1 - June 30), and radiology/other services benefits are separately limited
to five hundred dollars ($500) per SFY. Radiology/other services include, but
are not limited to, diagnostic X-rays, ultrasounds, and electronic
monitoring/machine tests, such as electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21)
years of age or older will be provided through prior authorization, if
medically necessary. The five hundred dollars ($500) per SFY diagnostic
laboratory services benefit limit, and the five hundred dollars
($500) per SFY radiology/other services benefit limit, do not apply to services
provided to recipients under twenty-one (21) years of age enrolled in the Child
Health Services/Early and Periodic Screening, Diagnostic and
Treatment (EPSDT) Program.
(1) The
following diagnoses are specifically exempt from the five hundred dollars
($500) per SFY diagnostic laboratory services benefit limit
, and
the five hundred dollars ($500) per SFY radiology/other services health benefit
limit
s:(a) Malignant
neoplasm;
(b) HIV infection;
and
(c) renal failure. The cost of
related diagnostic laboratory services, and radiology/other services will not
be included in the calculation of the recipient's five hundred dollars ($500)
per SFY diagnostic laboratory services benefit limits or the five hundred
dollars ($500) per SFY radiology/other services health benefit
limits.
(2) Drug
screening will be specifically exempt from the five hundred dollars ($500) per
SFY diagnostic laboratory services health benefit limit when the diagnosis is
for Opioid Use Disorder (OUD), and the screening is part of a
Medication Assisted Treatment (MAT) plan. The cost of
these screenings will not be included in the calculation of the recipient's
five hundred dollars ($500) diagnostic laboratory services health benefit
limit.
(3) Magnetic Resonance
Imaging (MRI) and Cardiac Catheterization procedures are specifically exempt
from the five hundred dollars ($500) per SFY outpatient diagnostic laboratory
services benefit limit or the five hundred dollars ($500) per SFY
radiology/other services health benefit limits. The cost of these procedures
will not be included in the calculation of the recipient's five hundred dollars
($500) per SFY diagnostic laboratory services benefit limit, or the recipient's
five hundred dollars ($500) per SFY radiology/other services health benefit
limits.
(4) Portable X-Ray Services
are subject to the five hundred dollars ($500) per SFY radiology/other services
benefit limit. Extensions of the benefit limit for recipients twenty-one (21)
years of age or older will be provided through prior authorization, if
medically necessary. Services may be provided to an eligible recipient in their
place of residence upon the written order of the recipient's physician.
Portable X-ray
services are limited to the following:
a. Skeletal films that involve arms and legs,
pelvis, vertebral column, and skull;
b. Chest films that do not involve the use of
contrast media; and
c. Abdominal
films that do not involve the use of contrast media.
(5) Two (2) chiropractic X-rays are covered
per SFY. Chiropractic X-Ray Services are subject to the five
hundred dollars ($500) benefit limit per SFY for radiology/other services.
Extensions of the radiology/other services benefit limit for recipients
twenty-one (21) years of age or older will be provided through prior
authorization, if medically necessary.
12. Prescribed drugs, dentures, and
prosthetic devices; and eyeglasses prescribed by a physician skilled in
diseases of the eye or by an optometrist a. Prescribed Drugs
(1) Each recipient age twenty-one (21) or
older may have up to six (6) prescriptions each month under the program. Family
Planning, tobacco cessation, prescription drugs for opioid
or alcohol use disorder as part of a Medication Assisted Treatment
plan, EPSDT, high blood pressure, hypercholesterolemia blood
modifiers, diabetes and respiratory illness inhaler prescriptions do not count
against the prescription limit.
(2)
Effective January 1, 2006, the Medicaid agency will not cover any Part D drug
for full-benefit dual eligible individuals who are entitled to receive Medicare
benefits under Part A or Part B.
(3) The Medicaid agency provides coverage, to
the same extent that it provides coverage for all Medicaid recipients, for the
following excluded or otherwise restricted drugs or classes of drugs, or their
medical uses - with the exception of those covered by Part D plans as
supplemental benefits through enhanced alternative coverage as provided in
42 C.F.R. §
423.104 (f)(1)(ii)(A) - to
full benefit dual eligible beneficiaries under the Medicare Prescription Drug
Benefit - Part D.
The following excluded drugs, set forth on the Arkansas
Medicaid Pharmacy Vendor's Website, are covered:
a. select agents when used for weight
gain
b. select agents when used for
the symptomatic relief of cough and colds
c. select prescription vitamins and mineral
products, except prenatal vitamins and fluoride
d. select nonprescription drugs
(4) The State will reimburse only
for the drugs of pharmaceutical manufacturers who have entered into and have in
effect a rebate agreement in compliance with Section 1927 of the Social
Security Act, unless the exceptions in Section 1902(a)(54), 1927(a)(3), or
1927(d) apply. The State permits coverage of participating manufacturers'
drugs, even though it may be using a formulary or other restrictions.
Utilization controls will include prior authorization and may include drug
utilization reviews. Any prior authorization program instituted after July 1,
1991 will provide for a 24-hour turnaround from receipt of the request for
prior authorization. The prior authorization program also provides for at least
a seventy-two (72) hour supply of drugs in emergency
situations.
ATTACHMENT
3.1-B
State/Territory: ARKANSAS
AMOUNT, DURATION, AND SCOPE OF SERVICES PROVIDED
MEDICALLY NEEDY GROUP(S):
4d.
Tobacco cessation counseling services for pregnant women
[X] Provided [] No limitations [] With limitations*
e. Medication-Assisted Treatment
for opioid use disorders when provided as part of a Medication Assisted
Treatment plan
[X] Provided [] No limitations [] With limitations*
5a. Physicians' services, whether
furnished in the office, the patient's home, a hospital, a nursing facility, or
elsewhere.
[X] Provided [] No limitations [] With limitations*
b. Medical and surgical services
furnished by a dentist (in accordance with section 1905(a)(5)(B) of the Act).
[X] Provided [] No limitations [] With limitations*
*Description provided on attachment.
2a. Outpatient Hospital Services (Continued)
Non-Emergency Services
Outpatient hospital services other than those which qualify as
emergency, outpatient surgical procedures and treatment, and therapy services
are covered as non-emergency services.
Benefit Limit
Outpatient hospital services are limited to a total of twelve
(12) visits a year. This yearly limit is based on the
State Fiscal Year - July 1 through June 30. Outpatient hospital
services include the following:
* non-emergency outpatient hospital and related physician and
nurse practitioner services; and
* outpatient hospital therapy and treatment services and
related physician and nurse practitioner services.
For services beyond the 12-visit limit, an extension of
benefits will be provided if medically necessary. The following diagnoses are
considered categorically medically necessary and do not require prior
authorization for medical necessity: Malignant neoplasm; HIV infection; renal
failure; opioid use disorder when the visit is part of a Medication Assisted
Treatment plan, and pregnancy. All other diagnoses are subject to prior
authorization before benefits can be extended.
Outpatient hospital services are not benefit limited for
recipients in the Child Health Services (EPSDT) Program.
2b. Rural Health Clinic Services
5. Services of nurse midwives; and
6. Visiting nurse services on a part-time or
intermittent basis to home-bound patients (limited to areas in which there is a
shortage of home health agencies).
Rural health clinic ambulatory services are defined as any
other ambulatory service included in the Medicaid State Plan if the rural
health clinic offers such a service (e.g. dental, visual, etc.). The "other
ambulatory services" that are provided by the rural health clinic will count
against the limit established in the plan for that service.
Medication Assisted Treatment visits do not count against the
Rural Health Clinic encounter benefit limit when the diagnosis is for opioid
use disorder and is part of a Medication Assisted Treatment plan.
2c. Federally qualified health
center (FQHC) services and other ambulatory services that are covered under the
plan and furnished by a FQHC in accordance with Section 4231 of the State
Medicaid Manual) NCFA - Pub.
45-4).
Federally qualified health center services are limited to
sixteen (16) encounters per client, per State Fiscal Year (July 1 through June
30) for clients twenty-one (21) years or older. The applicable benefit limit
will be considered in conjunction with the benefit limit established for
physicians' services, medical services furnished by a dentist, office medical
services furnished by an optometrist, certified nurse midwife services, rural
health clinic encounters, and advanced practice registered nurse services, or a
combination of the seven.
Benefit extensions will be available if medically necessary.
Clients under age twenty-one (21) in the Child Health Services (EPSDT) Program
are not benefit limited.
FQHC hospital visits are limited to one (1) day of care for
inpatient hospital covered days regardless of the number of hospital visits
rendered. The hospital visits do not count against the FQHC encounter benefit
limit.
Medication Assisted Treatment visits do not count against the
FQHC encounter benefit limit when the diagnosis is for opioid use disorder and
is part of a Medication Assisted Treatment plan.
3. Other Laboratory and X-Ray Services
Other professional and technical laboratory and
radiological services are covered when ordered and provided under the direction
of a physician or other licensed practitioner of the healing arts within the
scope of his or her practice, as defined under
42 CFR
440.30 in an office or similar facility other
than a hospital outpatient department or clinic.
Diagnostic laboratory services benefits are limited to five
hundred dollars ($500) per State Fiscal Year (SFY, July 1-June 30), and
radiology/other services benefits are limited to five hundred dollars ($500)
per SFY. Radiology/other services include, but are not limited to, diagnostic
X-rays, ultrasounds, and electronic monitoring/machine tests, such as
electrocardiograms (ECG or EKG).
Extensions of the benefit limit for recipients twenty-one (21)
years of age or older will be provided through prior authorization, if
medically necessary. The five hundred dollars ($500) per SFY diagnostic
laboratory services benefit limit, and the five hundred dollars ($500) per SFY
radiology/other services benefit limit, do not apply to services provided to
recipients under twenty-one (21) years of age enrolled in the Child Health
Services/Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
Program.
(1) The following diagnoses
are specifically exempt from the five hundred dollars ($500) per SFY diagnostic
laboratory services benefit limit, and the five hundred dollars ($500) per SFY
radiology/other services health benefit limits:
(a) Malignant neoplasm;
(b) HIV infection; and
(c) renal failure. The cost of related
diagnostic laboratory services and radiology/other services will not be
included in the calculation of the recipient's five hundred dollars ($500) per
SFY diagnostic laboratory services benefit limit or the five hundred dollars
($500) per SFY radiology/other services health benefit limit.
(2) Drug screening will be
specifically exempt from the five hundred dollars ($500) per SFY diagnostic
laboratory services health benefit limit when the diagnosis is for Opioid Use
Disorder (OUD), and the screening is part of a Medication Assisted Treatment
(MAT) plan. The cost of these screenings will not be included in the
calculation of the recipient's five hundred dollars ($500) diagnostic
laboratory or radiology/other services health benefit limits.
(3) Magnetic Resonance Imaging (MRI) and
Cardiac Catheterization procedures are specifically exempt from the five
hundred dollars ($500) per SFY outpatient diagnostic laboratory services
benefit limit or five hundred dollars ($500) per SFY radiology/other services
health benefit limit. The cost of these procedures will not be included in the
calculation of the recipient's five hundred dollars ($500) per SFY diagnostic
laboratory services benefit limit or the recipient's five hundred dollars
($500) per SFY radiology/other services health benefit limit.
(4) Portable X-Ray Services are subject to
the five hundred dollars ($500) per SFY X-ray services benefit limit.
Extensions of the benefit limit for recipients twenty-one (21) years of age or
older will be provided through prior authorization, if medically necessary.
Services may be provided to an eligible recipient in their residence upon the
written order of the recipient's physician. Portable X-ray
services are limited to the following:
a. Skeletal films that involve arms and legs,
pelvis, vertebral column, and skull;
b. Chest films that do not involve the use of
contrast media; and
c. Abdominal
films that do not involve the use of contrast media.
(5) Two (2) chiropractic X-rays are covered
per SFY. Chiropractic X-Ray Services are subject to the five hundred dollars
($500) benefit limit per SFY for radiology/other services. Extensions of the
radiology/other services benefit limit for recipients twenty-one (21) years of
age or older will be provided through prior authorization, if medically
necessary.
4a. Nursing
Facility Services - Not Provided
4c. Family Planning Services
(1) Comprehensive family planning services
are limited to an original examination and up to three (3) follow-up visits
annually. This limit is based on the state fiscal year (July 1 through June
30).
4d.
(1) Face-to-Face Tobacco Cessation Counseling
Services provided (by):
[X] (i) By or under
supervision of a physician;
[X] (ii)
By any other health care professional who is legally authorized
to furnish such services under State law and who is authorized to provide
Medicaid coverable services
other than tobacco cessation
services; * or
(iii) Any other health care
professional legally authorized to provide tobacco cessation services under
State law
and who is specifically
designated
by the Secretary in regulations. (None are designated at this time)
*Describe if there are any limits on who can provide these
counseling services
Arkansas Medicaid does not limit who can provide these
counseling services at this time so long as they meet (ii) and
(iii).
**Any benefit package that consists of
less than four (4) counseling sessions per quit attempt, with
a minimum of two (2) quit attempts per 12-month period (eight (8) per year)
should be explained below.
(2) Face-to-Face Tobacco Cessation Counseling
Services Benefit Package for Pregnant Women
Provided: [x] No limitations [] With limitations*
*Any benefit package that consists of less
than four (4) counseling sessions per quit attempt, with a minimum of two (2)
quit attempts per 12-month period (eight (8) per year) should be explained
below.
4e.
Prescription drugs for treatment of opioid use disorder
a.
Preferred prescription drugs
(preferred on the PDL) used for treatment of opioid or alcohol use
disorder require no prior authorization and do not count against the monthly
prescription limits when prescribed as part of a Medication Assisted Treatment
plan.
12 Prescribed
drugs, dentures and prosthetic devices; and eyeglasses prescribed by a
physician skilled in diseases of the eye or by an optometrist
a. Prescribed Drugs
(1) Each recipient age twenty-one (21) or
older may have up to six (6) prescriptions each month under the program. Family
Planning, tobacco cessation, prescription drugs for opioid
or alcohol use disorder when part of a Medication Assisted
Treatment plan, EPSDT, high blood pressure, hypercholesterolemia,
blood modifiers, diabetes and respiratory illness inhaler prescriptions do not
count against the prescription limit.
(2) Effective January 1, 2006, the Medicaid
agency will not cover any Part D drug for full-benefit dual eligible
individuals who are entitled to receive Medicare benefits under Part A or Part
B.
(3) The Medicaid agency provides
coverage, to the same extent that it provides coverage for all Medicaid
recipients, for the following excluded or otherwise restricted drugs or classes
of drugs, or their medical uses - with the exception of those covered by Part D
plans as supplemental benefits through enhanced alternative coverage as
provided in 42 C.F.R. §
423.104 (f)(1)(ii)(A) - to
full benefit dual eligible beneficiaries under the Medicare Prescription Drug
Benefit - Part D.
The following excluded drugs, set forth on the Arkansas
Medicaid Pharmacy Vendor's Website, are covered:
a. select agents when used for weight
gain:
b. select agents when used for
the symptomatic relief of cough and colds:
c. select prescription vitamins and mineral
products, except prenatal vitamins and fluoride:
d. select nonprescription
drugs:
(4) The State will
reimburse only for the drugs of pharmaceutical manufacturers who have entered
into and have in effect a rebate agreement in compliance with Section 1927 of
the Social Security Act, unless the exceptions in Section 1902(a)(54),
1927(a)(3), or 1927(d) apply. The State permits coverage of participating
manufacturers' drugs, even though it may be using a formulary or other
restrictions. Utilization controls will include prior authorization and may
include drug utilization reviews. Any prior authorization program instituted
after July 1, 1991, will provide for a 24-hour turnaround from receipt of the
request for prior authorization. The prior authorization program also provides
for at least a 72-hour supply of drugs in emergency
situations.
ATTACHMENT
3.1-F
Page 29
OMB No.:0938-933
|
Citation
|
Condition or Requirement
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1. Describe any additional circumstances of "cause" for
disenrollment (if any).
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K. Information requirements for
beneficiaries
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Place a check mark to affirm state compliance.
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1932(a)(5) CFR 438.50
42 CFR
438.10
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X The state assures that its
state plan program complies with
42 CFR
42 438.10(i) for
information requirements specific to MCOs and PCCM programs operated under
section 1932(a)(1)(A)(i) state plan amendments. (Place a check mark to affirm
state compliance.)
|
|
1932(a)(5)(D) 1905(t)
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L. List all services that are excluded for
each model (MCO & PCCM)
|
|
The following PCCM exempt services do not require PCP
authorization:
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Dental Services
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Emergency hospital care
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Developmental Disabilities Services Community and
Employment
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Support
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Family Planning
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Anesthesia
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Alternative Waiver Programs
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Adult Developmental Day Treatment Services Core
Services only
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Disease Control Services for Communicable
Diseases
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ARChoices waiver services
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Gynecological care
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Inpatient Hospital admissions on the effective date of
PCP enrollment or on the day
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after the effective date of PCP enrollment
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Medication-Assisted Treatment Services for opioid use
disorder when part of a
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Medication Assisted Treatment plan
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Mental health services as follows:
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a. Psychiatry for services provided by a psychiatrist
enrolled in Arkansas Medicaid and practice as an individual practitioner
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b. Rehabilitative Services for Youth and
Children
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Nurse Midwife services
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ICF/IID Services
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Nursing Facility services
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Hospital non-emergency or outpatient clinic services on
the effective date of PCP
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enrollment or on the day after the effective date of
PCP enrollment.
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Ophthalmology and Optometry services
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Obstetric (antepartum, delivery, and postpartum)
services
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Pharmacy
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Physician Services for inpatients acute care
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Transportation
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Supplement 1 to Attachment 3.1-B
Page 1
October 1, 2023
State of Arkansas
1905(a)(29) Medication Assisted Treatment (MAT)
Citation: 3.1(b)(1) Amount, Duration, and Scope of Services:
Medically Needy (Continued)
1915(a)(29) __X___MAT as described and limited in Supplement 1
to Attachment 3.1-B.
ATTACHMENT 3.1 -B identifies the medical and remedial services
provided to the medically needy.
i.
General Assurance
MAT is covered under the Medicaid state plan for all Medicaid
clients who meet the medical necessity criteria for receipt of the service for
the period beginning October 1, 2020, and ending September 30, 2025.
ii. Assurances
a. The state assures coverage of Naltrexone,
Buprenorphine, and Methadone and all of the forms of these drugs for MAT that
are approved under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C.
355) and all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C.
262).
b. The state assures that Methadone for MAT
is provided by Opioid Treatment Programs that meet the requirements in 42
C.F.R. Part 8.
c. The state assures
coverage for all formulations of MAT drugs and biologicals for opioid use
disorder (OUD) that are approved under section 505 of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C.
355) and all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C.
262).
iii. Service Package
The state covers the following counseling services and
behavioral health therapies as part of MAT.
a) Please set forth each service and
components of each service (if applicable), along with a description of each
service and component service.
MAT is covered exclusively under section 1905(a)(29) for the
period of 10/01/2020 through 9/30/2025.
Services available:
1.
Individual Behavioral Health Counseling
2. Group Behavioral Health
Counseling
3. Marital/Family
Behavioral Health Counseling that involves the participation of a non-Medicaid
eligible is for the direct benefit of the client. The service must actively
involve the client in the sense of being tailored to the client's individual
needs. There may be times when, based on clinical judgment, the client is not
present during the delivery of the service, but remains the focus of the
service.
b) Please
include each practitioner and provider entity that furnishes each service and
component service.
1. Physicians, Physician
Assistants and Nurse Practitioners may provide counseling and behavioral health
therapies.
2. Licensed Behavioral
Health Practitioners: Licensed Psychologists (LP), Licensed Psychological
Examiners - Independent (LPEI), Licensed Professional Counselors (LPC),
Licensed Certified Social Workers (LCSW), Licensed Marital and Family
Therapists (LMFT). This group's role is to provide the behavioral and substance
use disorder counseling required.
c) Please include a brief summary of the
qualifications for each practitioner or provider entity that the state
requires. Include any licensure, certification, registration, education,
experience, training and supervisory arrangements that the state requires.
Physicians and Nurse Practitioners must be Arkansas
Licensed.
Physician Assistants must have a legal agreement to practice
under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners -
Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified
Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must
possess a current and valid Arkansas license.
iv. Utilization Controls
__X___ The state has drug utilization
controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in
place.
v. Limitations
Describe the state's limitations on amount, duration, and scope
of MAT drugs, biologicals, and counseling and behavioral therapies related to
MAT.
MAT drugs and biologicals are limited based on the FDA
indication and manufacturers' prescribing guidelines. Some medications are also
subject to status on the Preferred Drug List (PDL).
The preferred (PDL) agents for MAT
therapy do not require a PA.
The Arkansas Medicaid Pharmacy program removed the prior
authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas
State Law from Act 964 which prohibits a prior authorization for Medication
Assisted Treatment of Opioid Use Disorder. The removal of prior authorization
was for MAT treatment according to SAMHSA guidelines. In addition, on
1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C.
355), for all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C. 262) to be
covered, Arkansas instructed the pharmacy vendor to bypass the
non-rebate-participation, repackaged indicator, inner indicator, and prioritize
coverage of all the pharmacy MAT products.
PRA Disclosure Statement - This information is being collected
to assist the Centers for Medicare & Medicaid Services in implementing
section 1006(b) of the SUPPORT for Patients and Communities Act (P.L.
115-271) enacted on October 24, 2018. Section
1006(b) requires state Medicaid plans to provide coverage of
Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory
Medicaid state plan benefit for the period beginning October 1, 2020, and
ending September 30, 2025. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law.
An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid Office of
Management and Budget (OMB) control number. The OMB control number for this
project is 0938-1148 (CMS-10398 # 60). Public burden for all of the collection
of information requirements under this control number is estimated to take
about 80 hours per response. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for
reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork
Reduction Act Reports Clearance Officer, Mail Stop C
4-26-05, Baltimore, Maryland
21244-1850.
Supplement 5 to Attachment 3.1-A
Page 1
October 1, 2023
State of ARKANSAS
1905(a)(29) Medication-Assisted Treatment (MAT)
Citation: 3.1(a)(1) Amount, Duration, and Scope of Services:
Categorically Needy (Continued)
1905(a)(29) ___X__MAT as described and
limited in Supplement __5__ to Attachment 3.1-A.
ATTACHMENT 3.1-A identifies the medical and remedial services
provided to the categorically needy.
i. General Assurance
MAT is covered under the Medicaid state plan for all Medicaid
clients who meet the medical necessity criteria for receipt of the service for
the period beginning October 1, 2020 and ending September 30, 2025.
ii. Assurances
a. The state assures coverage of Naltrexone,
Buprenorphine, and Methadone, all of the forms of these drugs for MAT that are
approved under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C.
355), and all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C.
262).
b. The state assures that Methadone for MAT
is provided by Opioid Treatment Programs that meet the requirements in 42
C.F.R. Part 8.
c. The state assures
coverage for all formulations of MAT drugs and biologicals for
opioid use disorder (OUD)that are
approved under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C.
355) and all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C.
262).
iii. Service Package
The state covers the following counseling services and
behavioral health therapies as part of MAT.
a) Please set forth each service and
components of each service (if applicable), along with a description of each
service and component service.
MAT is covered exclusively under section 1905(a)(29) for the
period of 10/01/2020 through 9/30/2025.
Services available:
1.
Individual Behavioral Health Counseling
2. Group Behavioral Health
Counseling
3. Marital/Family
Behavioral Health Counseling that involves the participation of a non-Medicaid
eligible is for the direct benefit of the client. The service must actively
involve the client in the sense of being tailored to the client's individual
needs. There may be times when, based on clinical judgment, the client is not
present during the delivery of the service, but remains the focus of the
service.
b) Please
include each practitioner and provider entity that furnishes each service and
component service.
1. Physicians, Physician
Assistants, and Nurse Practitioners may provide counseling and behavioral
health therapies.
2. Licensed
Behavioral Health Practitioners: Licensed Psychologists (LP), Licensed
Psychological Examiners - Independent (LPEI), Licensed Professional Counselors
(LPC), Licensed Certified Social Workers (LCSW), Licensed Marital and Family
Therapists (LMFT), This group's role is to provide the behavioral and substance
use disorder counseling required
c) Please include a brief summary of the
qualifications for each practitioner or provider entity that the state
requires. Include any licensure, certification, registration, education,
experience, training, and supervisory arrangements that the state requires.
Physicians and Nurse Practitioners must be Arkansas
Licensed.
Physician Assistants must have a legal agreement to practice
under an Arkansas Licensed Physician per Arkansas statute.
Licensed Psychologists (LP), Licensed Psychological Examiners -
Independent (LPEI), Licensed Professional Counselors (LPC), Licensed Certified
Social Workers (LCSW), and Licensed Marital and Family Therapists (LMFT) must
possess a current and valid Arkansas license.
iv. Utilization Controls
__X___ The state has drug utilization
controls in place. (Check each of the following that apply)
_______ Generic first policy
___X__ Preferred drug lists
_______ Clinical criteria
___X__ Quantity limits
_______ The state does not have drug utilization controls in
place.
v. Limitations
Describe the state's limitations on amount, duration, and scope
of MAT drugs, biologicals, and counseling and behavioral therapies related to
MAT.
MAT drugs and biologicals are limited based on the FDA
indication and manufacturers' prescribing guidelines. Some medications are also
subject to status on the Preferred Drug List (PDL). The preferred
(PDL) agents for MAT therapy do not require a Prior
Authorization.
The Arkansas Medicaid Pharmacy program removed the prior
authorization for preferred Buprenorphine products on 1/1/2020, due to Arkansas
State Law from Act 964 which prohibits a prior authorization for Medication
Assisted Treatment of Opioid Use Disorder. The removal of prior authorization
was for MAT treatment according to SAMHSA guidelines. In addition, on
1/22/2021, per section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C.
355), for all biological products licensed
under section 351 of the Public Health Service Act (42 U.S.C. 262) to be
covered, Arkansas instructed the pharmacy vendor to bypass the
non-rebate-participation, repackaged indicator, inner indicator, and prioritize
coverage of all the pharmacy MAT products.
1905(a)(29) Medication-Assisted Treatment (MAT)
Amount, Duration, and Scope of Medical and Remedial Care
Services Provided to the Categorically Needy (continued)
PRA Disclosure Statement - This information is being collected
to assist the Centers for Medicare & Medicaid Services in implementing
section 1006(b) of the SUPPORT for Patients and Communities Act (P.L.
115-271) enacted on October 24, 2018. Section
1006(b) requires state Medicaid plans to provide coverage of
Medication-Assisted Treatment (MAT) for all Medicaid enrollees as a mandatory
Medicaid state plan benefit for the period beginning October 1, 2020, and
ending September 30, 2025. Under the Privacy Act of 1974 any personally
identifying information obtained will be kept private to the extent of the law.
An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid Office of
Management and Budget (OMB) control number. The OMB control number for this
project is 0938-1148 (CMS-10398 # 60). Public burden for all of the collection
of information requirements under this control number is estimated to take
about 80 hours per response. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for
reducing this burden, to CMS, 7500 Security Boulevard, Attn: Paperwork
Reduction Act Reports Clearance Officer, Mail Stop C
4-26-05, Baltimore, Maryland
21244-1850.
Section
I
172.100
Services not
Requiring a PCP Referral
The services listed in this section do not require a PCP
referral:
A. Adult Developmental Day
Treatment (ADDT) core services;
B.
ARChoices waiver services;
C.
Anesthesia services, excluding outpatient pain management;
D. Assessment (including the physician's
assessment) in the emergency department of an acute care hospital to determine
whether an emergency condition exists. The physician and facility assessment
services do not require a PCP referral (if the Medicaid beneficiary is enrolled
with a PCP);
E. Chiropractic
services;
F. Dental
services;
G. Developmental
Disabilities Services Community and Employment Support;
H. Disease control services for communicable
diseases, including testing for and treating sexually transmitted diseases such
as HIV/AIDS;
I. Emergency services
in an acute care hospital emergency department, including emergency physician
services;
J. Family Planning
services;
K. Gynecological
care;
L. Inpatient hospital
admissions on the effective date of PCP enrollment or on the day after the
effective date of PCP enrollment;
M. Mental health services, as follows:
1. Psychiatry for services provided by a
psychiatrist enrolled in Arkansas Medicaid and practicing as an individual
practitioner
2. Medication Assisted
Treatment for Opioid Use Disorder
3. Rehabilitative Services for Youth and
Children (RSYC) Program
N. Obstetric (antepartum, delivery, and
postpartum) services
1. Only
obstetric-gynecologic services are exempt from the PCP referral
requirement
2. The obstetrician or
the PCP may order home health care for antepartum or postpartum
complications
3. The PCP must
perform non-obstetric, non-gynecologic medical services for a pregnant woman or
refer her to an appropriate provider
O. Nursing facility services and intermediate
care facility for individuals with intellectual disabilities (ICF/IID)
services;
P. Ophthalmology
services, including eye examinations, eyeglasses, and the treatment of diseases
and conditions of the eye;
Q.
Optometry services;
R. Pharmacy
services;
S. Physician services for
inpatients in an acute care hospital, including direct patient care (initial
and subsequent evaluation and management services, surgery, etc.), and indirect
care (pathology, interpretation of X-rays, etc.);
T. Hospital non-emergency or outpatient
clinic services on the effective date of PCP enrollment or on the day after the
effective date of PCP enrollment;
U. Physician visits (except consultations,
which do require PCP referral) in the outpatient departments of acute care
hospitals but only if the Medicaid beneficiary is enrolled with a PCP and the
services are within applicable benefit limitations;
V. Professional components of diagnostic
laboratory, radiology, and machine tests in the outpatient departments of acute
care hospitals, but only if the Medicaid beneficiary is enrolled with a PCP and
the services are within applicable benefit limitations;
W. Targeted Case Management services provided
by the Division of Youth Services or the Division of Children and Family
Services under an inter-agency agreement with the Division of Medical
Services;
X. Transportation
(emergency and non-emergency) to Medicaid-covered services; and
Y. Other services, such as sexual abuse
examinations, when the Medicaid Program determines that restricting access to
care would be detrimental to the patient's welfare or to program integrity or
would create unnecessary hardship.
Section II
214.200
Medication Assisted Treatment
and Opioid Use Disorder or Alcohol Use Disorder Treatment Drugs
Medication Assisted Treatment for Opioid or Alcohol Use
Disorders is available to all qualifying Medicaid beneficiaries. All rules and
regulations promulgated within the Physician's provider manual for provision of
this service must be followed.
212.220
Services Furnished in
Collaboration with a Physician
Nurse practitioner services are performed in collaboration with
a physician or physicians.
A.
Collaboration is a process in which a nurse practitioner works with one (1) or
more physicians to deliver health care services within the scope of the
practitioner's expertise, with medical direction, and appropriate supervision
as provided for in jointly developed guidelines or other mechanisms as provided
by State law.
B. The collaborating
physician does not need to be present with the nurse practitioner when the
services are furnished or to make an independent evaluation of each patient who
is seen by the nurse practitioner.
C. Medication Assisted Treatment (MAT) for
Opioid or Alcohol Use Disorders is available to all qualifying Medicaid
beneficiaries. All rules and regulations promulgated within the Physician's
provider manual for provision of this service must be followed.
220.000
Benefit
Limits
A. Arkansas Medicaid clients
aged twenty-one (21) and older are limited to sixteen (16) FQHC core service
encounters per state fiscal year (SFY, July 1 through June 30).
The following services are counted toward the sixteen (16)
encounters per SFY benefit limit:
1.
Federally Qualified Health Center (FQHC) encounters;
2. Physician visits in the office, patient's
home, or nursing facility;
3.
Certified nurse-midwife visits;
4.
RHC encounters;
5. Medical services
provided by a dentist;
6. Medical
services provided by an optometrist; and
7. Advanced practice registered nurse
services in the office, patient's home, or nursing facility.
B. The following services are not
counted toward the sixteen (16) encounters per SFY benefit limit:
1. FQHC inpatient hospital visits do not
count against the FQHC encounter benefit limit. Medicaid covers only one (1)
FQHC inpatient hospital visit per Medicaid-covered inpatient day, for clients
of all ages.
2. Obstetric and
gynecologic procedures reported by CPT surgical procedure code do not count
against the FQHC encounter benefit limit.
3. Family planning surgeries and encounters
do not count against the FQHC encounter benefit limit.
4. Medication Assisted Treatment for Opioid
Use Disorder does not count against the FQHC encounter limit when it is the
primary diagnosis (View ICD OUD Codes).
C. Medicaid clients under the age of
twenty-one (21) in the Child Health Services (EPSDT) Program are not subject to
an FQHC encounter benefit limit.
272.501
Medication Assisted Treatment
and Opioid or Alcohol Use Disorder Treatment Drugs
Medication Assisted Treatment for Opioid or Alcohol Use
Disorders is available to all qualifying Medicaid beneficiaries. All rules and
regulations promulgated within the Physician's provider manual for provision of
this service must be followed.
Effective for dates of services on and after October 1,
2023, the following Healthcare Common Procedure Coding System Level II
(HCPCS) procedure codes are payable:
View or print the procedure codes for Hospital/Critical Access
Hospitals/ESRD services.
To access prior approval of these HCPCS procedure codes when
necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms
found at the DHS contracted Pharmacy vendor website.
252.448
Medication Assisted Treatment
and Opioid or Alcohol Use Disorder Treatment Drugs
Medication Assisted Treatment for Opioid or Alcohol Use
Disorders is available to all qualifying Medicaid beneficiaries. All rules and
regulations promulgated within the Physician's provider manual for provision of
this service must be followed.
Effective for dates of services on and after October 1,
2023, the following Healthcare Common Procedure Coding System Level II
(HCPCS) procedure codes are payable:
View or print the procedure codes for Nurse Practitioner
services.
To access prior approval of these HCPCS procedure codes when
necessary, refer to the Pharmacy Memorandums, Criteria Documents and forms
found at the DHS contracted Pharmacy vendor website.
211.105
Coverage of Medication Assisted
Treatment and Opioid Use Disorder or Alcohol Use Disorder Treatment
Drugs
Coverage of preferred prescription drugs (preferred on the PDL)
for opioid or alcohol use disorder are available without prior authorization to
eligible Medicaid beneficiaries. Products for other use disorders may still
require PA. Additional criteria can be found at the DHS contracted Pharmacy
vendor's website.
Coverage and Limitations
A. Reimbursement for preferred drugs is
available with a valid prescription when prescribed according to FDA approved
label.
B. Prescription drugs will
not count against the monthly prescription benefit limit and are not subject to
co-pay when used for a primary diagnosis of opioid or alcohol use
disorder.
C. FDA dosing and
prescribing limitations apply.
212.000
Exclusions
A. Products manufactured by non-rebating
pharmaceutical companies.
B.
Effective January 1, 2006, the Medicaid agency will not cover any drug covered
by Medicare Part D for full-benefit dual eligible individuals who are entitled
to receive Medicare benefits under Part A or Part B.
C. The Medicaid agency provides coverage, to
the same extent that it provides coverage for all Medicaid beneficiaries under
§ 1927 (d) of the Social Security Act, for the following excluded or
otherwise restricted drugs or classes of drugs, or their medical uses; with the
exception of those covered by Part D plans as supplemental benefits through
enhanced alternative coverage as provided in
42 CFR §
423.104 (f)(1)(ii) (A), to
full-benefit dual eligible beneficiaries under the Medicare Prescription Drug
Benefit - Part D.
The following excluded drugs are set forth on the DHS
Contracted Pharmacy Vendor website.
1.
Select agents when used for weight gain
2. Select agents when used for the
symptomatic relief of cough and colds
3. Select prescription vitamins and mineral
products, except prenatal vitamins and fluoride
4. Select nonprescription drugs
D. Medical accessories are not
covered under the Arkansas Medicaid Pharmacy Program. Typical examples of
medical accessories are atomizers, nebulizers, hot water bottles, fountain
syringes, ice bags and caps, urinals, bedpans, glucose monitoring devices and
supplies, cotton, gauze and bandages, wheelchairs, crutches, braces, supports,
diapers, and nutritional products.
213.100
Monthly Prescription
Limits
A. Each prescription for all
Medicaid-eligible clients may be filled for up to a maximum thirty-one-day
supply. Maintenance medications for chronic illnesses must be prescribed and
dispensed in quantities sufficient (not to exceed the maximum thirty-one-day
supply per prescription) to effect optimum economy in dispensing. For drugs
that are specially packaged for therapy exceeding thirty-one (31) days, the
days' supply limit (other than thirty-one (31)), as approved by the agency,
will be allowed for claims processing. Contact the Pharmacy Help Desk to
inquire about specific days' supply limits on specially packaged dosage units.
View or print the contact information for the DHS contracted
Pharmacy vendor.
B. Each
Medicaid-eligible client twenty-one (21) years of age and older is limited to
six (6) Medicaid-paid prescriptions per calendar month.
Each prescription filled counts toward the monthly prescription
limit except for the following:
1.
Family planning items. Including without limitation, birth control pills,
contraceptive foams, contraceptive sponges, suppositories, jellies,
prophylactics, and diaphragms;
2.
Prescriptions for Medicaid-eligible long-term care facility residents(must be
for Medicaid-covered drugs);
3.
Prescriptions for Medicaid-eligible clients under twenty-one (21) years of age
in the Child Health Services/Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) Program. (must be for Medicaid-covered drugs);
4. Prescriptions for opioid or alcohol use
disorder treatment;
5.
Prescriptions for tobacco cessation products;
6. Prescriptions for the treatment of high
blood pressure;
7. Prescriptions
for the treatment of hypercholesterolemia;
8. Blood modifier medications;
9. Prescriptions for the treatment of
diabetes; and
10. Inhalers to treat
respiratory illness.
C.
Living Choices Assisted Living Program clients are eligible for up to nine (9)
medically necessary prescriptions per month.
D. After the client has received the maximum
monthly benefit or the maximum monthly extended benefit, they will be
responsible for paying for their own medications for the remainder of the
month.
201.500
Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol
Use Disorder
Providers of Medication-Assisted Treatment (MAT) for Opioid or
Alcohol Use Disorder must be licensed in Arkansas and be enrolled with Arkansas
Medicaid.
201.510
Providers of Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use
Disorder in Arkansas and Bordering States
Providers of MAT in Arkansas and the six (6) bordering states
(Louisiana, Mississippi, Missouri, Oklahoma, Tennessee, and Texas) may be
included as routine services providers if they meet all participation
requirements for enrollment in Arkansas Medicaid and requirements outlined in
Section 201.500.
Reimbursement may be available for MAT covered in the Arkansas
Medicaid Program when treating Opioid or Alcohol Use Disorders. Claims must be
filed according to the specifications in this manual. This includes assignment
of ICD and HCPCS codes for all services rendered.
201.520
Providers of
Medication-Assisted Treatment (MAT) for Opioid or Alcohol Use Disorder in
States Not Bordering ArkansasA.
Providers in states not bordering Arkansas may enroll in the Arkansas Medicaid
Program as limited services providers only after they have provided services to
an Arkansas Medicaid eligible beneficiary and have a claim or claims to file
with Arkansas Medicaid.
To enroll, a non-bordering state provider must download an
Arkansas Medicaid application and contract from the Arkansas Medicaid website
and submit the application, contract, and claim to Arkansas Medicaid Provider
Enrollment. A provider number will be assigned upon approval of the provider
application and Medicaid contract. View or print the provider enrollment and
contract package (Application Packet). View or print Provider Enrollment Unit
contact information.
B.
Limited services providers remain enrolled for one (1) year.
1. If a limited services provider provides
services to another Arkansas Medicaid beneficiary during the year of enrollment
and bills Medicaid, the enrollment may continue for one (1) year past the most
recent claim's last date of service, if the enrollment file is kept
current.
2. During the enrollment
period, the provider may file any subsequent claims directly to the Medicaid
fiscal agent. Limited services providers are strongly encouraged to file
subsequent claims through the Arkansas Medicaid website because the front-end
processing of web-based claims ensures prompt adjudication and facilitates
reimbursement.
203.271
Medication-Assisted Treatment
Provider Role for Administering Opioid or Alcohol Use Disorder Services
SAMHSA defines Medication Assisted Treatment (MAT) as the use
of medications in combination with counseling and behavioral therapies for the
treatment of substance use disorders. A combination of medication and
behavioral therapies is effective in the treatment of substance use disorders
and can help some people to sustain recovery. This definition and other MAT
guidelines can be found at the SAMHSA website.
Only providers who have met the requirements of Section
201.500 may
prescribe medication required for the treatment of Opioid or Alcohol Use
Disorder for Arkansas Medicaid beneficiaries in conjunction with coordinating
all follow-up and referrals for counseling and other services. This program
applies only to prescribers of FDA-approved drugs for treatment of Opioid or
Alcohol Use Disorder and will not be reimbursed for the practice of pain
management.
263.100
Coverage of Drugs Used for Opioid or Alcohol Use Treatment
Coverage of preferred prescription drugs (preferred on the PDL)
for opioid or alcohol use disorder and tobacco cessation are available without
prior authorization to eligible Medicaid beneficiaries. Products for other use
disorders may still require PA. Additional criteria can be found at the DHS
contracted Pharmacy vendor's website.
Coverage and Limitations
A. Reimbursement for preferred drugs is
available with a valid prescription when prescribed according to FDA approved
label.
B. Prescription drugs for
treatment of opioid or alcohol use disorder will not count against the monthly
prescription benefit limit and are not subject to co-pay.
C. FDA dosing and prescribing limitations
apply.
292.920
Medication Assisted Treatment (MAT) for Opioid Use Disorder
There are two (2) methods of billing for MAT.
1. Method 1- Inclusive Rate
a. The inclusive method of billing shall be
used when all SAMHSA guideline services as set forth at a minimum in Section
230.000 are provided on the same
date of service by the same billing group.
i.
For new patients, the provider group shall use HCPCS code, modifier X2 and list
an Opioid Use Disorder ICD-10 code as primary. The performing provider must be
enrolled as a MAT provider and the claim will pay a single rate for all
services (Office Visit, counseling, case management, medication
induction/maintenance, etc). Drug and lab testing/screening will continue to be
billed separately, using an X2 modifier with the proper code for the test or
screen.
ii. For established
patients requiring continuing follow-up MAT treatment, the provider group shall
use HCPCS code, modifiers U8, X2, and list an Opioid Use Disorder ICD-10 code
as primary. The performing provider must be enrolled as a MAT provider and the
claim will pay a single rate for all follow-up services as indicated on the
treatment plan and set forth at a minimum in Section
230.000 (Office Visit, counseling
and medication induction/maintenance, etc). Drug and lab testing/screening will
continue to be billed separately, using an X2 modifier with the proper code for
the test or screen.
iii. For
established patients requiring maintenance follow-up MAT treatment, the
provider group shall use HCPCS code, modifiers U8, X4, and list an Opioid Use
Disorder ICD-10 code as primary. The performing provider must be enrolled as a
MAT provider and the claim will pay a single rate for all follow-up services as
indicated on the treatment plan and set forth at a minimum in Section
230.000 (Office
Visit, counseling and medication induction/maintenance, etc). Drug and lab
testing/screening will continue to be billed separately, using an X4 modifier
with the proper code for the test or screen.
iv. The specific HCPCS code and modifiers
found in the following link are required for billing the inclusive rate. View
or print the procedure codes and modifiers for MAT
services.
2.
Method 2 - Regular Fee-for-Service Rates
a.
The regular Fee-for-Service method of billing shall be used when all SAMHSA
guideline services as set forth at a minimum in Section
230.000 cannot be provided on the
same date of service, or cannot be provided by the same billing group who has
the MAT specialized performing provider; therefore, causing some SAMHSA
guideline services to be referred elsewhere.
i. For new patients, the MAT provider shall
use the appropriate E & M (office visit) code, add modifier X2, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X2 modifier for the
screenings required.
ii. For
established patients requiring continuing treatment, the MAT provider shall use
the appropriate E & M (office visit) code, add modifier X2, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X2 modifier for the
screenings required.
iii. For
established patients requiring maintenance treatment, the MAT provider shall
use the appropriate E & M (office visit) code, add modifier X4, and list an
Opioid Use Disorder ICD-10 code as primary. The provider shall use the proper
Lab and Urine Screening codes plus the additional X4 modifier for the
screenings required.
Allowable ICD-10 codes for Opioid Use Disorder may be found
here: (View ICD OUD Codes.)
Allowable lab and screening codes may be found here: (View Lab
and Screening Codes.)
Providers utilizing telemedicine, regardless of Method, shall
adhere to telemedicine rules listed in Sections
105.190 and
305.000 in addition to those
above. The provider at the distance site shall use both the GT modifier and the
X2 or X4 modifier on the service claim.
211.100
Rural
Health Clinic Core Services
Rural Health Clinic core services are as follows:
A. Professional services that are performed
by a physician at the clinic or are performed away from the clinic by a
physician whose agreement with the clinic provides that he or she will be paid
by the clinic for such services;
B.
Services and supplies furnished "incident to" a physician's professional
services;
C. Services provided by
non-physician, services of physician assistants, nurse practitioners, nurse
midwives, and specialized nurse practitioners when the provider is legally:
1. employed by, or receiving compensation
from a rural health clinic;
2.
under the medical supervision of a physician;
3. acting in accordance with any medical
orders for the care and treatment of a patient prepared by a physician;
and
4. acting within their scope of
practice by providing services they are legally permitted to perform by the
state in which the service is provided if the services would be covered if
furnished by a physician;
D. Services and supplies that are furnished
as an incident to professional services furnished by a nurse practitioner,
physician assistant, nurse midwife, or other specialized nurse
practitioner;
E. Visiting nurse
services on a part-time or intermittent basis to home-bound patients in areas
in which there is a shortage of home health agencies.
Note: For purposes of visiting nurse care, a home-bound
patient is one who is permanently or temporarily confined to his or her place
of residence because of a medical or health condition. Institutions, such as a
hospital or nursing care facility, are not considered a patient's
residence.
Note: A patient's place of residence is where he or she
lives, unless he or she is in an institution such as a nursing facility,
hospital, or intermediate care facility for individuals with intellectual
disabilities (ICF/IID); and
F. Medication Assisted Treatment (MAT) for
Opioid or Alcohol Use Disorders is available to all qualifying Medicaid
beneficiaries. All rules and regulations promulgated within the Physician's
provider manual for provision of this service must be followed.
218.100
RHC Encounter
Benefit Limits
A. Medicaid clients
under the age of twenty-one (21) in the Child Health Services (EPSDT) Program
do not have a rural health clinic RHC encounter benefit limit.
B. A benefit limit of sixteen (16) encounters
per state fiscal year (SFY), July 1 through June 30, has been established for
clients twenty-one (21) years or older. The following services are counted
toward the per SFY encounter benefit limit:
1.
Provider visits in the office, client's home, or nursing facility;
2. Certified nurse-midwife visits;
3. RHC encounters;
4. Medical services provided by a
dentist;
5. Medical services
provided by an optometrist;
6.
Advanced practice registered nurse (APRN) services in the office, client's
home, or nursing facility; and
7.
Federally qualified health center (FQHC) encounters.
Global obstetric fees are not counted against the service
encounter limit. Itemized obstetric office visits are not counted in the
limit.
The established benefit limit does not apply to individuals
receiving Medication Assisted Treatment for Opioid Use Disorder when it is the
primary diagnosis (View ICD OUD Codes).
Extensions of the benefit limit will be considered for services
beyond the established benefit limit when documentation verifies medical
necessity. Refer to Section
218.310 of this manual for
procedures for obtaining extension of benefits.
RULES SUBMITTED FOR REPEAL
Rule #1: PUB 85: Differential Response: A Family-Centered
Approach to Strengthen and Support Families
Rule #2: PUB 357: Child Maltreatment Investigation
Determination Guide
